A nurse is caring for a client who is 5 hours postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?
Adjust the rate of the bladder irrigant.
Irrigate the catheter.
Check the tubing for kinks.
Notify the provider.
The Correct Answer is C
Choice A reason:
Adjusting the rate of the bladder irrigant may be necessary if there is an issue with the flow or the amount of fluid, but it is not the first action to take. The nurse must first ensure that there is no mechanical obstruction causing the lack of drainage.
Choice B reason:
Irrigating the catheter could be the next step if checking the tubing does not resolve the issue. However, it is not the first action to take because if there is a kink in the tubing, irrigation will not be effective and could potentially cause harm.
Choice C reason:
The first action the nurse should take is to check the tubing for kinks because this is a common and easily correctable cause of obstruction in catheter drainage. If the tubing is kinked, straightening it may allow urine to drain properly.
Choice D reason:
Notifying the provider is important if the other interventions do not resolve the issue. However, it is not the first action to take. The nurse should first perform basic troubleshooting steps to identify and correct any simple mechanical issues with the catheter system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A reason:
Instructing the client to eat cooked foods only is a necessary precaution for immunosuppressed individuals. Cooking foods thoroughly can help eliminate harmful bacteria and other pathogens that could cause infection in a person with a weakened immune system.
Choice B reason:
Restricting visitors who have active infections is crucial in preventing the transmission of potentially harmful pathogens to the immunosuppressed client. Even minor infections in healthy individuals can be severe for someone with a compromised immune system.
Choice C reason:
Disposing of all linen in the trash after use is not a standard precaution for immunosuppressed clients. Used linens should be handled according to the healthcare facility's infection control policies, which often include laundering and not simply discarding in the trash.
Choice D reason:
Limiting the client from bathing daily is not a necessary precaution for immunosuppression. Maintaining good personal hygiene is important, and there is no need to restrict regular bathing unless there is a specific contraindication.
Choice E reason:
Donning a mask, gloves, and gown when caring for an immunosuppressed client can be part of standard precautions, especially if the client is in a protective environment or if the nurse is performing a procedure that has a high risk of contact with bodily fluids or if the client has a known infection.
Correct Answer is C
Explanation
Choice A reason:
Danazol is a synthetic steroid that is typically used to treat endometriosis and fibrocystic breast disease. It is not indicated for the treatment of benign prostatic hyperplasia (BPH) and could potentially worsen symptoms due to its androgenic effects.
Choice B reason:
Methyltestosterone is an anabolic steroid with androgenic properties, similar to the male hormone testosterone. It is used to treat men with testosterone deficiency. However, it is not used for BPH treatment and, like danazol, could exacerbate BPH symptoms due to its androgenic activity.
Choice C reason:
Finasteride is a 5-alpha reductase inhibitor that is commonly prescribed for the treatment of BPH. It works by inhibiting the conversion of testosterone to dihydrotestosterone (DHT), a hormone that contributes to prostate growth. By reducing DHT levels, finasteride can help shrink the prostate and alleviate urinary symptoms associated with BPH.
Choice D reason:
Fluoxymesterone is another anabolic steroid with testosterone-like effects. It is used to treat conditions associated with a deficiency or absence of endogenous testosterone. It is not suitable for BPH treatment and could potentially worsen the condition due to its androgenic properties.
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